Nepal Paediatric Society

Dedicated to the health of all Children

Paediatric Clinical
Standards

2023
 Contents
Common Conditions
» Paediatric Basic Resuscitation Protocol ..................................................................................................................................................5
» Triage and Management of the Child with Emergency Signs........................................................................................................6
» Transfer of the Sick Child .......................................................................................................................................................................... 10
» Febrile Child................................................................................................................................................................................................... 11
» Acute Gastroenteritis ................................................................................................................................................................................. 12
» Sepsis/Septic Shock Protocol .................................................................................................................................................................. 13
» Severe Acute Malnutrition ....................................................................................................................................................................... 15
» Snake Bite Management ........................................................................................................................................................................... 18

Respiratory Section

» Child with Breathing Difficulties ............................................................................................................................................................ 26

» Approach to the Child with Stridor ....................................................................................................................................................... 27
» Asthma ............................................................................................................................................................................................................ 28
» Croup (Acute Laryngotracheobronchitis)........................................................................................................................................... 31
» Pneumonia .................................................................................................................................................................................................... 33
» Management of Anaphylaxis ................................................................................................................................................................. 36

Poisoning Section
» Kerosene Poisoning .................................................................................................................................................................................... 38
» Acetaminophen (Paracetamol) Poisoning.......................................................................................................................................... 40
» OPC Poisoning .............................................................................................................................................................................................. 42

Neurology Section
» Acute Onset of Coma..................................................................................................................................................................................44
» Treatment of Prolonged Paediatric Seizures ..................................................................................................................................... 45

Neonatal Section
» Newborn Resuscitation Algorithm........................................................................................................................................................ 46
» Kangaroo Mother Care ............................................................................................................................................................................. 48

Appendices
» Paediatric Vital Signs Chart ...................................................................................................................................................................... 50
» SAM Volume Guidance Table .................................................................................................................................................................. 51
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Paediatric Basic Resuscitation Protocol

Unresponsive?

Safe approach, Stimulate, Shout for help,

Setting - Gloves
During CPR

Airway • Ensure high quality CPR: rate, depth and

Open airway by Head tilt + chin lift/jaw thrust. recoil
Is there any obstruction? If so, manage • Plan actions before interrupting CPR
• Give oxygen
• Vascular access – (after airway/breathing
Not breathing normally, no signs of life. assessment and treatment) using IV/IO
• Give adrenaline 0.1ml/kg of 1 in 10,000*
IV/IO every 3-5 minutes
Breathing • Consider advanced airway if possible
Give FIVE rescue breaths with bag and mask. • Continuous compressions if definitive
Make sure that chest rises – if it does not, airway – endotracheal tube – established
adjust airway position and consider adjunct. • Correct reversible causes
Add oxygen

Reversible causes
Circulation • Hypoxia
Check for signs of circulation – HR must be > 60bpm • Hypovolemia
Attach ECG monitoring/defibrillator if available • Hypo/Hyperkalemia/ metabolic
• Hypothermia
• Tension pneumothorax
If no signs of life, or HR<60, commence chest • Toxins
compressions. • Tamponade - cardiac
15 chest compressions: 2 ventilation breaths - • Thromboembolism
7 cycles per minute

Immediate post arrest care

Return of spontaneous circulation • Use ABCCCD approach
Stop CPR, • If possible, control oxygenation and
Recovery position, ventilation
Give oxygen, • Investigations
Monitor closely • Treat precipitating cause
• Temperature control

*If 1:10,000 adrenaline not available:

Use 0.01mL/kg of 1:1000 Adrenaline
=10mcg/kg (Recommend drawing up
the whole 1mL in 1:1000 adrenaline
concentration vial and dilute with 9mL 0.9%
Sodium Chloride for injection so 0.1mL/kg
dosage (10mcg/kg) is always administered.

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Triage and Management of the Child with Emergency Signs

• Start by looking for emergency signs – if any present, start treatment immediately
• Move the child to a treatment area as quickly as possible and call for help
• (Do not move neck if cervical spine injury possible)
• Ensure the most senior healthcare worker available assesses the patient as soon as possible

Airway or Breathing Problem • Quickly check inside mouth and remove visible secretions or
• Obstructed breathing foreign body
• Central cyanosis • If history of foreign body aspiration, give backslaps and
Yes chest/abdominal thrusts
• Severe respiratory distress (nasal
• Position and open the child’s airway (jaw thrust, chin lift)
flaring, grunting, head bobbing,
chest indrawing) - Age less than 1 year = Neutral position
• Weak/absent breathing - Age over 1 year = Sniffing position
• Give oxygen (aiming for oxygen saturations ≥ 94%
• If the child conscious and has severe respiratory distress then
prop them up in sitting position
• Diagnose and treat underlying cause
No
• If visible bleeding, apply direct pressure to stop blood loss
• If pulse not felt, start basic life support immediately
• Give oxygen if oxygen saturations < 94%
• Make sure the child is warm
If no evidence of severe malnutrition:
Circulation Problem • Insert IV cannula (if difficult to site cannula, insert IO needle
Cold hands instead)
+ - Give 10 ml/kg of normal saline or Ringer’s Lactate, only if
Weak and fast (or absent) Yes child has all these three signs of shock
radial pulse • If child looks pale, check Haemoglobin urgently
+ - Give blood transfusion if Hb <6 g/dl
Capillary refill time >2 seconds • Reassess early after first treatment and if no improvement,
= SHOCK consider further fluid bolus of 10 ml/kg of normal saline/Ringers
Lactate
• Diagnose and treat underlying cause
• Consider giving antibiotics (IV Ceftriaxone 80-100 mg/kg OD)
No • Manage airway of child (see above)
• Check blood sugar and if low/unable to check give IV Dextrose
5ml/kg 10% Dextrose
• If child currently convulsing
Coma or Convulsion - give oxygen to keep oxygen saturations ≥ 94%
• Convulsing (currently) Yes - give anti-convulsant: IV Diazepam, or if no IV access,
• Coma (Responding only to Pain rectal Diazepam (see Seizure Standard)
or Unresponsive on AVPU scale) • Diagnose and treat underlying cause (see Coma Standard)
If severe malnutrition present, see Severe Acute Malnutrition Standard
No If restless, irritable or floppy, see Coma Standard

Dehydration (Severe) • Make sure the child is warm

Lethargy plus 2 or more of: • If lethargic, check blood sugar and if low/unable to check give 5
• Sunken eyes ml/kg of 10% dextrose.
Yes
• Slow skin pinch If no severe malnutrition:
• Inability to drink • Insert IV line. If signs of shock give fluids, as above; if no shock
• Normally accompanied by give fluids as per WHO diarrhoea and dehydration guidance
diarrhoea If severe malnutrition present, see SAM Standard

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If the child has no emergency signs, quickly go on to look for priority signs:

Priority Signs
• These patients must not be left in a queue and must be seen early by senior healthcare worker
• All are vulnerable to early deterioration or may indicate severe disease
• All require ABCCCD assessment and treatment
• Remember 3TPRMOBB
• There may children in the queue with other problems who also have priority

Tiny any small child (<3months) or <5kg is high risk for deterioration and must be
seen early

Temperature high fever usually indicates sepsis, child can deteriorate quickly and must be
seen early; if signs are severe, must have antibiotics early

Trauma or other surgical if major, trauma pathway must be activated early; use C-ABCCCDE approach
(first C is control of visible haemorrhage); minor injuries may mask severe
injuries, call surgeon early

Pallor severe anaemia may indicate severe underlying illness

Poisoning specific antidotes, e.g. atropine for OP poisoning, must be given early

Pain this may indicate a severe problem; no child should be left in severe pain
without early assessment and treatment

Respiratory distress may be respiratory or indicate other severe illness, assess early, measure
oxygen saturations and give oxygen if <94%

Restless, Irritable or floppy check ABC, may indicate cerebral problem or signs of severe illness
(e.g. shock) assess early, check glucose, follow Coma Standard

Referral all urgent referrals to your hospital must be seen early; treatment may not
have started, and deterioration may have occurred
Malnutrition visible signs of severe malnutrition and/or MUAC< 11.5cm, high risk for
deterioration: see SAM Standard for emergency fluid management

Oedema (both feet) may indicate severe malnutrition (or heart failure or other conditions)
Burns activate burn protocols early and requires early attention to ABC and pain
relief
Bleeding control visible bleeding, look for cause, think external or internal cause

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Paediatric Triage Form

Date: Ticket arrival time: Triage time: Age:

Clinician name _______________ Sex: M/F

Patient name_________________ Weight:

Presenting complaint:

Please complete the following

RED: EMERGENCY SIGNS - circle if present  MUST BE
assessment in all cases
SEEN IMMEDIATELY in ER
If in OPD  Healthcare worker accompany to ER
Temperature ____
Airway
HR _____
- Obstructed breathing
Breathing Respiratory rate ____
- Weak/absent breathing
Conscious level (please circle):
- Central cyanosis Alert Voice Pain
- Severe respiratory distress (Grunting, chest indrawing, nasal Unresponsive
flaring, head bobbing)
Circulation:
- Cold hands + Weak and fast/absent radial pulse + CRT >2seconds
= SHOCK
Coma or Convulsion
- Coma (responding only to Pain or Unresponsive on AVPU)
- Actively convulsing
Dehydration (Severe)
- Lethargy + 2 or more of the following
 Sunken eyes
 Slow skin pinch
 Inability to drink/severe vomiting

YELLOW: PRIORITY SIGNS – circle if present  put in YELLOW area in ER

3T 3P 3R MOBB
Tiny (less than 3months old) Pallor Restless Malnutrition
Trauma Pain (severe) Respiratory distress Oedema (both feet)
Temperature (>39.5oC) Poisoning Referral Burns
Bleeding (severe)

GREEN: If none of above present – Green (Non-urgent)  place in general waiting area / send to OPD

Clinical assessment
Time:

Clinician Name:

Designation:

Clinical findings:

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Paediatric Triage

RED: EMERGENCY SIGNS  MUST BE SEEN IMMEDIATELY in ER

If in OPD  Healthcare worker accompany to ER

Airway
- Obstructed breathing

Breathing
- Weak/absent breathing
- Central cyanosis
- Severe respiratory distress (Grunting, chest indrawing, nasal flaring,
head bobbing)

Circulation
- Cold hands + Weak and fast/absent radial pulse + CRT >2seconds = SHOCK

Coma
- Coma (responding only to pain or unresponsive on AVPU)

Convulsion
- Actively convulsing

Dehydration (Severe)
- Lethargy + 2 or more of the following
 Sunken eyes
 Slow skin pinch
 Inability to drink/ severe vomiting

YELLOW: PRIORITY SIGNS  put in YELLOW area in ER

3P MOBB
Malnutrition
Oedema (both feet)
Burns
Bleeding (severe)

GREEN: If none of above present – Green (Non-urgent)  place in general waiting area / send to OPD

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Transfer of the Sick Child

Assessment and decision for referral

to be made by the most senior member of the team

Communicate with the guardians

Decide about accompanying guardian and

healthcare professional* during transfer

Communication about the • Continue care until handover As far as possible,

child between the referring to the transfer team: • Communicate with the higher
and the transfer team: • Resuscitate and stabilize centre where patient is planned
• Situation • Consider and optimize the to be transferred.
• Background balance between time spent in • Confirm availability of services
• Assessment stabilization vs the urgency for before transfer.
• Recommendation transfer Communicate about:
• Clinical details
• Relevant test results
Transfer team ensures Handover necessary
• Treatment provided
availability of: equipment and medicines
• Condition at transfer
• Oxygen (with back-up), tube, (labelled) to the transfer team.
• Possible services needed and
oxygen mask Provide transport incubators if recommendations
• AMBU bag with mask (function appropriate and available • Estimated time for arrival
checked) Provide documents:
• IV fluids, IV giving set Case summary with
• Infusion/syringe pumps if interventions, condition at
available referral and recommendations Receiving centre prepares for
• Any emergency use
receiving the child in ER and/or
medications recommended by
in an intensive care unit
referring team

• Transfer the child in • Receive the child in ER or ICU

appropriate vehicle (four- • Ensure receipt of all
wheeler ambulance most documents and information
common) from referring centre
• Ensure continuity of treatment • Take handover of events
recommended by referring during transfer
team • Assess and provide necessary
• Make additional interventions immediate interventions
as necessary as much as • Contact referring centre for
possible with available any relevant information not
resources and expertise eg. * Sick child should ideally be available in documents
anti-seizure medications, IV transferred accompanied by a • Counsel the guardians
fluids, inotropes etc. healthcare professional. • Start definitive treatment

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Management of the Febrile Child

*Investigations:
CBC/CRP/Blood culture and sensitivity
LP if < 30 days old
Fever in children >38.5 oC
Urine culture and sensitivity
Chest Xray: If cough, high WCC and
fever >38.5oC

Emergency Signs present ?

Absent Present Start Emergency Treatment

Age < 3 months Age > 3 months

Sepsis work-up:
Active child with Sick child with presence
Do investigations*
presence or absence of or absence of features of
features of specific illness specific illness

Age 1 to 3
Age < 30 days
months

Positive sepsis
work-up and/or Admit:
Investigations and treat
clinical concern
on outpatient basis - Supportive treatment
- Continue investigations for cause
- Treat any specific cause found
Negative sepsis work-up:
Admit and Observe in hospital - Antibiotics as per local
monitor clinically. guideline (Ceftriaxone)
Or
Antibiotics as per
local guideline Outpatient treatment
and follow up

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Sepsis/Septic Shock Protocol

WHO definition of sepsis: Diagnose shock if all of the below features present:
‘Sepsis is a life-threatening condition that arises Cold extremities
when the body’s response to infection causes life Fast and weak peripheral pulses
threatening injury to its own tissues and organs.’ CRT >3secs

Suspect septic shock when there is:

• Hypotension despite adequate fluid resuscitation
• Requirement of inotropes
• Oliguria
• CRT>3 secs
• Toe/core temp gap >3° C
• Reduced consciousness
• Elevated lactate
• Acute respiratory distress syndrome
• Evidence of other organ dysfunction

Management
Timeline ABCCCDE Look for What to do
0 min Airway Secretion/bleeding Provide airway support:
Obstruction If unconscious-
Added sounds - Position airway
Cyanosis - Suction if required
- Consider airway adjuncts
Maintainable/ not
(e.g. Guedel airway, nasopharyngeal airway)
maintainable
Breathing Respiratory rate + SpO2 If signs of respiratory distress or SpO2 <94%:
Respiratory distress:
- indrawing, nasal flaring, Give high flow oxygen (via NRM at 10 L/min)
grunting, head bobbing

Auscultation:
- wheezing, crackles,
reduced air entry
5 min Circulation Cold hands Obtain IV access (2 in shock)
Peripheral pulses weak and - Use IO if 3 unsuccessful attempts with IV cannulation
fast or absent
Send CBC, RFT, LFT, blood culture, coagulation profile, blood
CRT >3 secs group, CRP, serum calcium

Diagnose shock if all of the If shock: NS/RL 10 ml/kg over 30 mins, repeat if necessary at 10
ml/kg, till 40 ml/kg
above present - NB. must assess if has SAM, in which case give 15ml/kg DRL
fluid bolus over 1hr first and reassess

IV antibiotics (broad spectrum within 1 hour)

Start inotropes after 40 ml/kg IVF bolus if features of shock

1 hour persist:
- Dopamine 5-20 mcg/kg/min if no improvement,
- Add peripheral adrenaline 0.03-1 mcg/kg/min
- If unresponsive, IV hydrocortisone 2 mg/kg
Give IV calcium if low

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Coma Check glucose If Blood glucose <54mg/dL (3mmol/L), give 5 ml/kg 10%
Convulsion Assess AVPU dextrose IV/IO
If convulsion: NEPAS Treatment of Prolonged Paediatric
Seizures Standard
Exposure Temperature Manage hypo and hyperthermia
Bite mark Stop active external bleeding by pressure bandage
bleeding Replace with PRBC if significant bleeding
Dehydration Check for: Follow WHO protocol
Sunken eyes
Skin pinch lethargy
Thirst/ Able to drink

Target of therapy

ACTION
Target Titrate IVF and inotropes

• CRT<2 secs Transfuse PRBC: 10-15 ml/kg if Hb <6g/dL +

haemodynamically unstable:
• Normal pulse rate and volume If not met - hypotension
• Normal MAP - persistent/progressive end organ
dysfunction
• Urine output >1 ml/kg/hour - persistence of lactate >2mmol/L
- hypoxia
• Hb >6 g/dL - requiring vasopressor

Transfuse Platelets: 15ml/kg if platelets are

<30,000/microlitre

AFTER RESUSCITATION MONITORING

• Search for underlying source of infection • Monitor vitals at least hourly

• Detailed history and examination • Consider complications (progression of
• Other investigations: urine culture, stool shock, AKI, coagulopathy)
culture and other • If no improvement after 48 hours: consider
• Lumbar puncture if possibility of meningitis 2nd line antibiotics, or alternate diagnosis

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SEVERE ACUTE MALNUTRITION: Diagnosis and Assessment

DIAGNOSIS Diagnose Severe Acute Malnutrition (SAM) if a child has any of the following:
- Weight for length Z-score <-3
- Mid-Upper Arm Circumference (MUAC) <11.5cm (if age >6 months)
- Bilateral pitting oedema

ASSESSMENT

Assess child using an ABCCCDE approach

Check: Temperature, Respiratory Rate, Heart Rate, Oxygen Saturations, Blood glucose

STEP 1 – TREAT/PREVENT HYPOGYLCAEMIA

If Blood Glucose < 54mg/dl (3mmol/l) and child conscious (or unable to check blood glucose)
give 50ml of 10% Dextrose or 10% Sucrose solution (1 rounded teaspoon of sugar in 3.5 tablespoons/50ml of
water) orally or via NG tube
If child unconscious or convulsing, give 5ml/kg of 10% Dextrose IV
Encourage child to breast feed/aim to start feeds as soon as possible

Assess for Medical Complications/Danger Signs:

• Child lethargic or unconscious or fitting
• Child vomits everything
• Child has severe diarrhoea and/or dehydration
• Child has fever (T > 38.5oC) or low temperature (T < 35oC axillary or <35.5oC rectal)
(See Step 2 – Treat/Prevent Hypothermia and Step 3 – Treat/Prevent Infection for guidance on management
of these complications)
• Child has fast breathing (Respiratory rate >60 if < 2 months, or > 50 from 2-12 months, or >40 from 1-5 years
or>30 if >5 years or any chest indrawing (if > 6 months) –> give oxygen
• Child is not able to drink or breastfeed and/or does not eat
• Child has severe anaemia (palmar pallor) –> check urgent haemoglobin
• Child has severe oedema (+++, generalised including both feet, hands, arms and face)

Perform Appetite Test: Are they able to eat test dose of RUTF (ready-to-use therapeutic food)?

Ask about: Feeding/Appetite, Breastfeeding, Vomiting, Diarrhoea, Stools and Urine, Cough, Fevers, Swelling, and
further questions as appropriate (duration of symptoms, immunisation status)

Child has 3+ oedema or No Medical Complications or

CRITERIA FOR Medical complication/danger Danger Signs
ADMISSION sign (see above) or Demonstrates appetite by
Poor appetite or eating RUTF
Infant < 6 months with SAM: If oedema present only 1+ or 2+
ADMIT to

INPATIENT CARE OUTPATIENT CARE

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Severe Acute Malnutrition: INITIAL MANAGEMENT

1) TREAT/PREVENT If Blood Glucose < 54mg/dl (3mmol/l) and child conscious give 50ml of 10% Dextrose
HYPOGLYCAEMIA or 10% Sucrose solution (1 rounded teaspoon of sugar in 3.5 tablespoons/50ml of
water) orally or via NG tube
If child unconscious or convulsing, give 5ml/kg of 10% Dextrose IV
Give first feed of F75 orally (or NGT if vomiting or unable to take orally) as soon as
possible – Please see below appendix with volume guidance table

2) TREAT/PREVENT If axillary temperature is <35oC or rectal temperature <35.50C:

HYPOTHERMA Feed child immediately as above, check blood sugar (if not already done)
Actively warm child: put hat and warm clothes on them, place a heater or lamp
nearby, or place skin-to-skin with mother or carer and cover them
Commence intravenous antibiotics if child not already receiving them
Re-check temperature every 30 minutes until > 360C

3) TREAT/PREVENT Assess children with a history of vomiting or diarrhoea for shock and dehydration
DEHYDRATION – assume dehydration in all children with history of recurrent vomiting or frequent
watery stools and recent change in appearance/weight loss

Suspect shock if child has cold extremities, CRT >3 seconds and peripheral
pulses weak and fast or absent with decreased conscious level (lethargy or
unconsciousness)

If dehydration suspected: If signs of shock:

Give 5ml/kg of ReSoMal every 30 minutes for 2 (Use IV fluids with extreme caution in children
hours orally or by NGT with SAM)
If ReSoMal not available use F75 or make up ReSoMal Give 15ml/kg of DRL IV, monitor closely for signs
according to WHO recipe (don’t use standard ORS) of fluid overload and check observations every 10
Monitor closely and reassess child after 2 hours minutes
– if child still dehydrated continue 5-10ml/ Commence intravenous antibiotics if child not
kg ReSoMal alternate hours with F75 up to a already receiving them
maximum of 10 hours If shock does not improve after 1 hour, give blood
Give Zinc 10-20mg a day for 10-14 days (unless transfusion (10ml/kg over 3 hours)
receiving F75/RUTF which already has Zinc added)
Management of anaemia - Give blood
(10ml/kg over 3 hours) to children with SAM if:
Hb < 4g/dL
Hb <6g/dL and signs of respiratory distress

4) CORRECT ELECTROLYTE IMBALANCE

Start feeding with F75 (with contains the necessary electrolytes, do not give diuretics

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5) TREAT/PREVENT INFECTION

Give all children with SAM antibiotics:

If child is well with no medical complications/danger signs – give oral Amoxicillin
If child has medical complications/danger signs or is shocked or hypothermic – give IV/IM antibiotics
(Ampicillin and Gentamycin)
Give all children in malarial areas (Terai) Chloroquine and Primaquine for 3 days
Give Albendazole to all children > 1 year of age, if not already had in last 6 months
(Dose: 1 – 2 years: give 200mg stat, over 2 years: give 400mg)

6) CORRECT MICRONUTRIENT DEFICENCIES

Give Vitamin A to all children (unless have oedema/have received in last month)
- Child under 6 months 50 000 IU stat PO
- Child aged 6 – 12 months 100 000 IU Stat PO
- Child aged over 12 months 200 000 IU Stat PO

Iron and Folic acid should not be given routinely – consider giving after 1st 14 days if child has moderate/
severe anaemia

If child not receiving F75/100/RUTF may need to consider supplementing other micronutrients

7) START CAUTIOUS RE-FEEDING

Start feeding as soon as possible with F75 – give via NGT if vomiting, very lethargic or unable to take orally,
encourage breast-feeding on top if appropriate
Give 130ml/kg/day of F75 divided into 8 feeds (every 3 hours) – give feeds day and night
In children with severe oedema consider starting with 100ml/kg/day
For children < 6 months, refer to Nepal IMAM guidelines

MONITOR CHILD CLOSELY FOR COMPLICATIONS - Severe acute malnutrition has a high mortality: monitor
children very closely for complications such as hypoglycaemia, hypothermia, infection, vomiting and diarrhoea.
Refer to NEPAL IMAM guideline for Steps 8-10, and guidance on transitioning to stage 2 of management.

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Snake Bite Management

Chart One

Complaint of Snake Bite

CONFIRM
(Refer to charts two and three for
signs and symptoms)

No signs and symptoms Systemic signs and symptoms Local signs and symptoms

Treat and
Observe for 24
observe for 24
Hours
Hours

Neurological Symptoms Coagulopathy

Manage Airway Manage Airway

Manage Breathing Manage Breathing
Manage Circulation Manage Circulation: Give
Manage Coma Normal Saline or Blood
Manage Convulsion Transfusion if indicated
Administer Antivenom if Manage Coma
indicated (Chart Four) Manage Convulsion
Intubate and put on ventilator Administer Antivenom if
if indicated indicated (Chart Four)

Principles of management of snake bite

Management of respiratory depression and shock

Timely administration of antivenom
Timely initiation of assisted ventilation

A: Airway clearance, intubate if needed

B: O2 by any means available. Bag and Mask ventilation. Mechanical Ventilator (Neurotoxic envenomation)
C: If hypotensive, or profuse bleeding: NS, Blood Transfusion, vasopressor support

For Neurotoxicity:
Inj. Atropine 0.02 mg/kg up to 0.6mg
Followed by Inj. Neostigmine 0.025 – 0.04 mg/kg up to 0.6 mgIV or IM every 30 minutes.

Adapted from:
National Guideline for Snake Bite Management in Nepal, DoHS, 2019

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Local Features of Snake Bite

Chart Two

Bite Mark
• Fang mark may be obvious as single puncture, dual puncture or marks of multiple tooth marks. There may
only be scratch mark.
• Presence or appearance of fang mark is not helpful in diagnosing venomous versus non-venomous snake
bite:
Venomous snake can have single puncture if one tooth is broken or nonvenomous may have distinct
two punctures if they have large teeth. Krait bite may leave no mark at all.
• Arm or lower limb bite occurs in victim who unintentionally steps on or otherwise disturbs a snake while
working in the field or walking: This is common in farmers, foresters, students etc.
• Nocturnal snake bite occurs to people sleeping on ground, the bite may occur in trunk or other body
parts.
Local Effects

• Envenoming usually produces local effects in the form of swelling and local pain with
Cobra or without erythema or discoloration at the bite site. Blistering, bullae formation and
local necrosis are also common. If it is infected, there may be abscess formation.

Krait • Usually do not cause signs of local envenoming and can be virtually painless.

• Envenoming results in local pain and tissue damage, characterized by swelling,

blistering, bleeding, and necrosis at the bite site, sometimes extending to the whole
limb. Consequences of the local envenoming may last for weeks and can produce
significant morbidity.
Viper • Russell’s viper envenoming may lead to persistent bleeding from fang marks, wounds
or any injured parts of the body due to venom induced coagulopathy.
• Bleeding disorder is usually not seen in pit viper bite in Nepal. However, recently it is
reported (case report) from southern and eastern Nepal.
• Swelling or tenderness of regional lymph node denotes venom spread.

Adapted from:
National Guideline for Snake Bite Management in Nepal, DoHS, 2019

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Systemic Features of Snake Bite

Chart Three

Neurotoxic features (Common with Cobra and Krait):

• Ptosis (unable to look up)

• Ophthalmoplegia (double vision)
• Pupillary dilation (often not reactive to light)
• Difficulty in opening mouth
• Inability to protrude tongue beyond the incisors
• Difficulty in swallowing
• Inability to hold the neck (head) upright
• Limb weakness
• Loss of gag reflex
• Respiratory failure

Features of coagulopathy (common with Vipers):

• Excess bleeding from venipuncture site

• Gum bleeding
• Epistaxis
• Haemoptysis
• Melena
• Haematuria, PV bleed
• Subconjunctival haemorrhage
• Petechiae, Purpura, ecchymosis
• Visceral bleed, Intracranial bleed, Intra-abdominal bleed
• Hypovolemic shock and AKI
• Prolonged BT and CT, PT and INR. Abnormal 20-minute whole blood clotting test (20WBCT)

Adapted from:
National Guideline for Snake Bite Management in Nepal, DoHS, 2019

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Indication and Use of Antivenom

Chart Four

Antivenom available in Nepal is polyvalent and effective against: Russell's viper, Common Cobra and
Common Krait.
Antivenom should be used as early as possible when indicated i.e. when patient develops systemic features of
envenomation.
Antivenom administration has risk of anaphylactic reactions.

Indications:

• Ptosis, external ophthalmoplegia, broken neck sign, respiratory

Evidence of Neurotoxicity
difficulty, etc.

• Evidence of coagulopathy primarily detected by 20 WBCT or

visible spontaneous systemic bleeding, bleeding gums, etc.,
Evidence of Coagulopathy including myoglobinuria and hemoglobinuria.
• Rapid extension of local swelling (more than half of limb) which
is not due to pit vipers or tight tourniquet application.

Evidence of Cardiovascular Collapse • Shock and hypotension (in case of Russell’s viper bite).

• Traditionally Acute Kidney Injury (AKI) is an indication for

Evidence of Acute Kidney Injury antivenom therapy. However, AKI in absence of haematotoxic
manifestation is highly unlikely.

Reconstitution of Antivenom:
Each vial is diluted with 10 ml sterile water supplied with antivenom.

Administration:
Prophylactic Adrenaline to be given routinely prior to antivenom administration.
Reconstituted antivenom is further diluted in 3 to 5 ml per kg body weight of NS or D5 and administered as
infusion at 2ml/minute.

Dose:
For neurotoxic features: 10 vials initially, then if neurologic features DETERIORATE, 5 vials every hour. Max. total
20 Vials.
For Haematotoxic features: 10 vials initially, then if after six hours 20WBCT or other coagulation test abnormal,
five vials. Max. total 20 vials.

Adapted from:
National Guideline for Snake Bite Management in Nepal, DoHS, 2019

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Referral
Chart Five

Indication for referral

Patient requiring

• Respiratory support
• Deteriorating neurological manifestations
• Surgical intervention - necrosis / fasciotomy
• Spontaneous persistent bleeding in spite of antivenom administration in adequate dose
• Co-morbid diseases like heart failure or chronic kidney disease
• Acute kidney injury

Where to refer

• Centre with facilities to provide mechanical ventilation in case of neuroparalysis

• In case of AKI - centre with dialysis facilities
• In case of necrosis (or likely need for fasciotomy) - centre with experience in management of snake bite
wound

What to do before transfer

• Insert IV line
• Give antivenom if features of systemic envenoming exist. Adrenaline prophylaxis must be given before
starting antivenom
• If antivenom not available - give neostigmine and atropine in case of neurotoxic envenoming

Instructions while referring/transferring the patient

• Explain the reason for referral to the patient party.

• If possible provide prior information to the receiving centre, identify the receiving hospitals capability
for providing assisted ventilation - consider alternative hospital if ventilation is not available.
• Arrange for an ambulance and transfer the patient to centre where mechanical ventilator and dialysis
facilities are available.
• It is critical to provide airway support while transferring patient. This should be done with the help of
accompanying staff.
• A referral note should mention about the treatment given (specially antivenom) and the condition of the
patient at the time of transfer.
• Instruct one staff to accompany the patient during transportation if required.

Adapted from:
National Guideline for Snake Bite Management in Nepal, DoHS, 2019

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First Aid Treatment of Snake Bite

Chart Six

REASSURANCE

• The victim may be very frightened and anxious. Reassure victim that most of the suspected snake bite are
caused by non-venomous snakes. Reassure victim that snake bite is a treatable condition.

IMMOBILISATION

• Immobilise the bitten limb with a splint or sling. Any cloth or bandage may be used for this. Any form of
movement causing muscle contraction like walking, undressing will increase absorption and spread of venom
by squeezing veins and lymphatics.
• Pressure immobilisation (PIB) is believed to delay in spread of venom to systemic circulation and PIB
method is commonly recommended by many experts in pre-hospital management. However, the pressure-
immobilisation technique demands special equipment and training and is not considered practical for
general use in Nepal. Searching for the material to apply pressure immobilisation may cause delay in seeking
much needed healthcare for treatment of envenoming. Moreover, envenoming by Cobra and Viper snakes
causes local tissue damage and localization of toxin by PIB may worsen tissue damage.
• Pressure pad immobilisation has been found to be useful in Myanmar. Its applicability in Nepal is not known.
• Remove rings, jewellery, tight fittings and clothing and avoid any interference with the bite wound to help
prevent infection, decrease absorption of venom and decrease local bleeding.

RAPID TRANSPORT

• The victim should be transported to the hospital where they can receive medical care.
• The most common cause of death due to snake bite envenoming in Nepal is due to respiratory paralysis (and
rarely shock due to bleeding from Russell’s viper envenoming). In one community-based study, 80% of
patients with envenoming died even before reaching a snake bite treatment centre or hospital. Rapid
transport using motorcycle has been found to decrease mortality in Nepal. The victim is seated and held
between driver and pillion rider.

Adapted from:
National Guideline for Snake Bite Management in Nepal, DoHS, 2019

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Twenty-minutes Whole Blood Clotting Test

Chart Seven

Procedure and interpretation

• Use the necessary precautions for taking blood.

• Place 3 ml of freshly sampled venous blood in a small, new, dry, glass tube.
• Leave the tube standing undisturbed for 20 minutes at ambient temperature.
• Gently tip the tube once.
• If the blood is still liquid (unclotted) and runs out, the patient has uncoagulable blood.

Timing of test

• The test should be performed on patient on admission, who is suspected to be bitten by Russell’s viper.
• If on admission the test shows uncoagulable blood or if the patient has spontaneous bleeding, the test
should be repeated every six hours after initiation of antivenom.
• If on admission the test is normal (coagulable blood), the test should be repeated when spontaneous
bleeding occurs.

Important notes

• If the tube used is not made of ordinary glass or if it has been cleaned with detergent, the tube’s wall may not
stimulate clotting and the test will be invalid.
• If the result of the test is doubtful, repeat the test in duplicate, and include a blood sample from a control
(non-envenomed person such as a relative).
• Do not confuse whole blood with serum; it is normal to have the clear serum running out when the tube is
tipped after 20 minutes.
• It is not indicated in identified Cobra or Krait bite.

Adapted from:
National Guideline for Snake Bite Management in Nepal, DoHS, 2019

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Common types of Snakes in Nepal

Chart Eight

Cobra species

Krait Species

Russell's and Pit Vipers

Adapted from:
National Guideline for Snake Bite Management in Nepal, DoHS, 2019

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Child with Breathing Difficulties

Causes of breathing difficulties in children
A. Pathology within Respiratory system
• Upper airway: Croup, Epiglottitis, Retropharyngeal abscess, Foreign body
• Lower airway: Tracheitis, Asthma, Bronchiolitis
• Lung parenchyma: Pneumonia, ARDS, Pulmonary oedema
• Pleura: Pneumothorax, Empyema
B. Pathology outside Respiratory system
• Pathology increasing respiratory drive: Diabetic ketoacidosis, Cardiac failure, Shock, Poisoning,
Anxiety
• Pathology decreasing respiratory drive: Coma, Convulsion, raised intracranial pressure
• Neuromuscular disorder: Guillain-Barré Syndrome (GBS)
• Others: Peritonitis, Abdominal distension
All children presenting in Emergency need primary assessment and stabilisation as per PAT/ABCCCDE approach.
Once stabilised secondary assessment is done to find the possible cause of breathing difficulties as shown in the
algorithm below.
Approach to the cause of breathing difficulties
Child with breathing difficulties

Presence of signs of respiratory Start emergency treatment immediately

distress or failure with supplemental oxygen

Look for stridor or wheeze

Stridor present No Stridor/No wheeze Wheeze present

Croup (See NEPAS Croup Standard) Bronchiolitis

Epiglottitis
Foreign body Asthma (See NEPAS Asthma Standard)
Diphtheria
Anaphylaxis (See NEPAS Anaphylaxis Standard) Wheeze associated LRTI

Fast breathing

With Fever & Chest With No Fever & No With Basal crepitation,
crepitation Chest crepitation hepatomegaly, murmur

Pneumonia
(See NEPAS Pneumonia DKA, Anaemia Congestive cardiac failure
Standard)

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Approach to the Child with Stridor

Algorithm 2: Recognising the Cause of Acute Stridor

All causes can lead to acute airway obstruction

ABCCCDE assessment
Do not upset the child, leave on parent’s lap,
Febrile Afebrile
get senior help if severe, avoid throat
examination and any distressing procedure

Bacterial tracheitis
Toxic looking
No drooling Diagnostic features
• High fever
• Barking cough

No Yes

Drooling

Acute Anaphylaxis
Laryngotracheobronchitis Diagnostic Features
Diagnostic Features • Angioedema
• Barking cough • Urticarial
• Mild fever • Wheeze
• Hoarse voice • Exposure to known allergens

Diptheria Epiglottitis Foreign body inhalation

Diagnostic Features Diagnostic Features Diagnostic Features
• High fever • High fever • Sudden onset
• Large cervical lymph nodes • Soft stridor • History of chocking
• Grey membrane on pharynx • Rest in tripod position • Cough
• Bloody nasal discharge

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Asthma
Acute severe asthma
• Asthma is the most common chronic inflammatory disease of childhood that is manifested by airflow obstruction.
• Airway obstruction results from triad of smooth muscle spasm, mucosal inflammation and mucous plugging.
• Severity depends on the degree of wheeze, respiratory rate and pulsus paradoxus.
• Arterial oxygen saturation by a pulse oximeter (SpO2) is useful in assessing severity, monitoring progress and
predicting outcome in acute asthma.
• More intensive inpatient treatment is likely to be needed for children with SpO2 <90% on air after initial
bronchodilator treatment.

Table. Severity of Asthma Attack

Moderate Acute severe asthma Life-threatening asthma

Able to talk Too breathless to feed or talk Exhaustion

May be agitated Usually agitated Drowsy, confused

Use of accessory muscles; Poor respiratory effort

suprasternal retractions

Respiratory rate: Respiratory rate:

<30/min (>5 years) >30/min (>5 years)
<40/min (2-5 years) >40/min (2-5 years)

Heart rate: Heart rate: Bradycardia

100-120 beats/min >120 beats/min (>5 years) Hypotension
>130 beats/min (2-5 years)

Wheeze throughout exhalation Wheeze during both inhalation and Silent chest
exhalation

SpO2 90-95% in room air SpO2 <90% in room air Hypoxia despite oxygen therapy

Consider whether this could be

anaphylaxis

(Adapted from APLS 6th edtn and IAP text book of PICU protocol. 3rd edtn)

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Management of Asthma

Initial Assessment ABC

No Yes
Any of these: Drowsiness, confusion, silent chest

Severe/ life
Mild to Moderate
threatening

Oxygen to maintain SpO2 > 94%

Short acting beta-agonist (SABA): Needs PICU admission
Salbutamol MDI 100mcg/actuation
- For 0-5 yrs: 2-4 puffs every 20 mins for 1 hour
- For ≥6yr: 4-10 puffs every 20 mins for 1 hour
If unable to take MDI: Continue ongoing treatment
Salbutamol nebulisation (5mg/ml) - High flow oxygen
-For 0-5 yrs: 2.5 mg - Oxygen driven SABA nebulisation
-For ≥6yrs: 5 mg - Ipratropium nebulisation 6-8 hourly
Ipratropium bromide - Systemic corticosteroid
-For < 2 years 125 mcg every 20-30 mins initially - IV Magnesium Sulphate 25-40 mg/kg over
-For ≥ 2 years 250 mcg every 20-30 mins initially 30 minutes as a single dose
- Adrenaline (1mg/ml 1:1000) SC. OR IM: 0.01
and
mg/kg (max dose 0.5 mg); may repeat after
- Prednisolone 2mg/kg (max 40 mg)
15-30 min
- Terbutaline: SC 0.01mg/kg/dose (max 0.3
Continue treatment: mg) doses may be repeated every 20 mins
Deteriorating:
SABA as needed and for up to 3 doses. OR IV Loading dose 10
Will need PICU
reassess after 1 hour or mcg/kg over 10 mins followed by 0.1 to 1
admission
earlier if worsening mcg/kg/min continuous infusion
- Consider Aminophylline Loading dose 5
Improving: mg/kg IV over 20 minutes*
Symptoms relieved Continuous infusion of 0.5 to 1 mg/kg/h
Maintaining SpO2 >94% in room air - Non-invasive ventilation (NIV)

Plan for discharge

- SABA as and when required
- Controller to be continued
- Prednisolone to continue for 3 days Intubation and Mechanical ventilation if
- Follow up in 2-3 days clinically indicated:
- Assess inhaler technique - Poor or deteriorating respiratory effort
OR
- Altered mental status
Ventilator strategy OR
- Low breath rate with long expiratory - Increased work of breathing causing child to
phase. Judicious use of PEEP (3-5 cmH2O) get exhausted
OR
- Ketamine infusion in intubated patient - Refractory hypoxia & hypercarbia despite
(20- 60mcg/kg/min) maximum oxygen therapy or NIV

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Asthma Emergency Treatment

Table: Medications in Asthma
Oxygen High-flow
Nebulised ß2 bronchodilator- 0.5 ml for <5 years or 1 ml for 5 years or above as required according to
Salbutamol (5 mg/ml) solution severity and response.

Nebulised ipratropium bromide 125 mcg for < 2 years and 250 mcg for ≥ 2 years every 20-30 mins initially

Prednisolone: 2 mg/kg/day for 3 days (max. dose/day 40 mg) or

Intravenous hydrocortisone succinate: Loading dose 8-10 mg/kg (max
300 mg) followed by 4-5 mg/kg 6 hourly on day 1, every 12 hourly on day
2 once daily thereafter on day 3 and if needed on day 4 and day 5.
Steroid
Intravenous Methylprednisolone:
Loading dose of 2 mg/kg (max 60 mg) followed by 1 mg/kg every 6 hourly
on day 1 every 12 hourly on day 2 once daily thereafter on day 3 and
if needed on day 4 and day 5.

IV Magnesium sulphate 25-40 mg/kg over 30 minutes as a single dose

Injection Adrenaline SC or IM: 0.01 mg/kg (max dose 0.5 mg); may repeat after 15-30 min.
(1mg/ml 1:1000)

Loading dose 5 mg/kg IV over 20 minutes Continuous infusion of 0.5 to

IV Aminophylline*
1 mg/kg/h

IV Loading dose 10 mcg/kg over 10 mins followed by 0.1 to 1 mcg/kg/

min continuous infusion.
Terbutaline**
SC 0.01mg/kg/dose (max 0.3 mg) doses may be repeated every 20 mins
for up to 3 doses.
*Only if the child is not on oral theophylline other methylxanthines (APLS 6th edn)
** Source-IAP management algorithm for common pediatric illness (2016)

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Croup (Acute Laryngotracheobronchitis)

Assessment of severity: The severity assessment of croup generally incorporates a number of clinical features, which
include the presence and degree of chest wall retractions, whether stridor is present at rest, and evaluation of the
child’s mental status (e.g. agitation, anxiety, lethargy).

Clinical Parameter Mild Moderate Severe

Behaviour Normal Intermittent mild agitation Increasing agitation,
drowsiness
Stridor* No stridor, or only when Intermittent stridor at rest Persistent stridor at rest
active or upset
Respiratory Rate Normal Increased Marked increase or
decrease
Use of Accessory Muscles None or minimal Moderate chest wall Marked chest wall
retraction retraction
Oxygen saturations** Hypoxia

* Loudness of stridor is not a good indicator of severity of obstruction. Soft stridor in the presence of worsening
clinical picture may be a sign of imminent airway obstruction
**Not necessary to measure oxygen saturations in children with mild to moderate croup
**Hypoxia is a late sign which indicates life-threatening croup
(Source: Clinical practice guideline. The Royal Children’s Hospital Melbourne)

Risk factors for severe croup include:

• pre-existing narrowing of upper airways
• previous admissions with severe croup
• young age: uncommon <6 months old, rare <3 months of age. Consider alternative diagnosis and causes of
upper airway obstruction

Specific management of Croup:

Follow the algorithm below. Oxygen should be administered for hypoxia, and supportive care with analgesics
and antipyretics is reasonable for fever and discomfort.

Specific treatment for Epiglottitis:

• All potentially distressing interventions, such as IV insertion, blood sampling, and throat examination with
tongue depressor should be deferred until the airway has been secured.
• Intubation is likely required. Examination under anaesthesia and tracheal intubation with smaller ET than
usually required for child’s size. ENT surgeon capable of doing tracheostomy should be present.
• After securing airway, blood sample for culture should be sent followed by third generation cephalosporin for 10
days.

Suspect anaphylaxis or inhaled foreign body if a child presents with a very sudden onset of upper airway obstruction,
without fever or other signs of illness

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Management of Croup (Adapted from APLS 6th, IAP PICU protocol 3rd and Clinical practice guideline.
The Royal Children’s Hospital Melbourne)

CROUP

Mild Moderate Severe

Dexamethasone 0.15 mg/kg orally Nebulised Adrenaline 0.4-0.5

OR ml/kg/dose of 1:1,000 solution
Prednisolone 1mg/kg orally (max 5 ml) in normal saline (to
OR total volume of 5 ml)
Inhaled Budesonide 2mg AND
Repeat dose after 12 hours if Inj. Dexamethasone
clinically indicated 0.6 mg/kg (max 12 mg) IM
AND
Supplemental oxygen

Stridor free at rest, Deterioration

discharge

Good response Minimal or poor response

Consider discharge at 4 hours Consider longer observation (>4hrs post

post Adrenaline nebulisation: Adrenaline nebulisation) for a child who:
if stridor free at rest - presents overnight
- is from remote area with no medical
facility
- present with repeated attack of stridor
during the same illness
- has risk factors for severe croup

Deterioration Repeat Adrenaline

nebulisation.
Consider alternative
diagnosis AND PICU
admission

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Pneumonia
(Source: IMNCI/WHO)

Cough and/or difficulty in breathing with or Fast breathing:

without fever, plus any of the following? Age <2 months RR > 60/min
Fast breathing, Lower chest wall indrawing Age 2-12 months, RR > 50/min
Age 1-5 years, RR > 40/min
Yes No
Increased work of breathing (WOB):
Intercostal, subcostal & suprasternal
retraction
Nasal flaring and use of accessory
muscles

Abnormal breath sounds:

Pneumonia No Pneumonia/Probably URTI Diminished breath sounds, scattered
crackles and/or wheeze

Oral Amoxicillin (40 mg/kg/ dose twice a day for 5 days)

Treat wheeze with Neb Salbutamol or MDI Salbutamol
Avoid cough syrup

Advise to follow-up in 2 days or earlier if the child

becomes sicker or is unable to drink or breastfeed

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Systematic Assessment of Children with Non-severe Pneumonia at Follow-up

(Source FB-IMNCI)

Assess the patient’s condition

Yes Complete the course

Has the patient improved?
of Antibiotic therapy
No

Yes
Is the patient worse? Admit or refer to higher facility

No

Are Antibiotics being used Yes Correct administration and

incorrectly? follow up in 48 hours

No

Yes Continue same antibiotic and

Does child have a wheeze?
add bronchodilator
No

Suspect tuberculosis, HIV/ AIDS Yes Perform investigations and provide

or sign of severe malnutrition appropriate management

No

Continue same antibiotic for 24 hours

No
Yes
Reassess. Is there improvement? Complete the treatment course

No

Admit or Refer Indication for admission:

- Age < 6 months
- Multiple lobe involvement
- Immunocompromised state
- Toxic appearance
- Hypoxia
- Dehydration
- Vomiting or inability to tolerate oral fluids or
medications
- No response to appropriate oral antibiotic
therapy
- Inability of caregivers to administer medications
at home
- Inability to come for follow-up

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Severe Pneumonia
(Adapted From IMNCI)

Cough and/or difficult breathing with at least one of the following:

- Central cyanosis
- Severe respiratory distress
• Respiratory rate >70/min
• Head nodding, grunting, severe chest indrawing
• Inability to breastfeed or drink due to respiratory distress
- Emergency signs like coma, convulsion, shock
- Presence of crackles, bronchial breath sounds, decreased breath sounds

*Supplemental O2 IF SpO2 <94% in

Severe Pneumonia
presence of other emergency signs

- Admit ** Add inj Cloxacillin 25 mg/kg/dose 6

- Supplemental oxygen or CPAP: if hourly for suspected Staphylococcal
SpO2<92%* infection.
- NPO/ IV fluid
- Inj Ampicillin IV 50 mg/kg/dose 6 hourly *** Inj. Ceftriaxone 50 mg/ kg/dose twice
daily or Cefotaxime 50 mg/kg/dose every 6
AND hours
- Inj Gentamicin IV 5 mg/kg once a day**
- CXR

Monitor at least 3 hourly for emergence of new

danger signs and/or complications

Worsen at any time

Reassess at 48 hours

No improvement or deterioration
Improved despite adequate therapy

- Review the diagnosis

- Review for wheeze
Complete antibiotics - CXR for complications (e.g empyema; increased or new
onset)
Duration of antibiotics - Upgrade antibiotics to third generation
Clinical response within 48 Cephalosporin***
hours: 7 days - Add inj Cloxacillin** if Staphylococcal infection is
Clinical response after 48 suspected
hours: 10 days - Refer for possible ventilator support if not improved
despite above therapy

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Management of Anaphylaxis
(Adapted from APLS)

Prodromal symptoms - itching, flushing,

Signs and symptoms of Anaphylaxis facial swelling, urticaria, abdominal pain
Difficulty breathing, noisy breathing,
Call for help cyanosis, agitation, collapse
Give oxygen Poor pulse volume and pallor, tachycardia
Remove allergen with hypotension, wheeze, stridor,
Injection Adrenaline IM (1:1000) 0.01 ml/kg respiratory or cardiac arrest

Partial obstruction/
Complete obstruction Assess Airway
stridor

Prepare for intubation,

Repeat IM Adrenaline if no response
anticipate difficult intubation,
Nebulised Adrenaline
prepare for cricothyrotomy,
IV Hydrocortisone
consult ENT/Anaesthetist

Apnoea Assess Breathing Wheeze

Bag and Mask Ventilation

Repeat IM Adrenaline if no response
Repeat IM Adrenaline if no
Nebulised Salbutamol
response
Can repeat IV Hydrocortisone
Nebulised Adrenaline
Consider IV Aminophylline
IV Hydrocortisone

No pulse Assess Circulation Shock

Start Life support CPR Fluid resuscitation

(10 ml/kg crystalloid bolus, repeat
if necessary)
Reassess - Are clinical
Consider Adrenaline infusion (if
symptoms persistent?
fluid refractory shock)

Repeat Adrenaline and Observe for 4-6 hours

Yes No
follow above steps and reassess
Discharge

No Yes
Asymptomatic after observation

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Medicines in Anaphylaxis
(Adapted from APLS-6th Edition)

Dosage by age
Medicines
< 6 months 6 mths to 6 years 6-12 years >12years

Adrenaline IM 150 micrograms 150 micrograms 300 micrograms 500 micrograms

Pre-hospital practitioner (0.15ml of 1:1000) (0.15ml of 1:1000) (0.3ml of 1:1000) (0.3ml of 1:1000)

Adrenaline IM 10 microgram/kg 0.1ml/kg of 1:1 0000 (infants and young children)

In-hospital practitioner OR 0.01ml/kg of 1:1 000 (older children)

Titrate 1 micrograms/kg given over 1 min (range 30 sec to 10 mins)

Adrenaline IV
Dilute 0.01mg/kg up to 10 ml and give 1ml/kg
Hydrocortisone
25 mg 50 mg 100 mg 200 mg
(IM or slow IV)

Age based dosage is advised because weight based dosage of 1:1000 Adrenaline when used in infants and small
children will result in very small volumes being drawn.

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Asymptomatic Kerosene Poisoning Management Algorithm

History of kerosene ingestion with normal breathing OR Smell of kerosene with normal breathing

No gastric lavage or Emesis

Monitoring of SpO2 & Respiration

CXR at 6 hours & observe for 12 hours

Normal Pneumonitis

Discharge after 12 hours of observation Admit

Counselling to prevent recurrence Monitoring of SpO2 & Respiration
Not to store kerosene in water or beverage Supportive treatment if symptomatic
bottles
Follow flowchart for symptomatic child if
CXR shows multiple small patchy opacities
with ill-defined margins

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Symptomatic Kerosene Poisoning Management Algorithm

MILD RESPIRATORY DISTRESS: SUDDEN DETERIORATION SEVERE RESPIRATORY DISTRESS:

Tachypnoea & alert IN RESPIRATION: Grunting & drowsy

MANAGEMENT - Mediastinal shift MANAGEMENT

- No gastric lavage - CPAP/NIV
- Humidified O2 - Hyperresonance
- MV if NIV not possible or not
- NPO/ IV fluids
effective (be cautious of air leak)
- Monitoring in HDU/ICU - Absent breath sounds
- Monitor SpO2 & vitals
- Antibiotics
- Salbutamol inhalation if
wheezing - Close monitoring

Pneumothorax

Once stable: - Needle thoracocentesis If CXR bilateral infiltrates

- NG/oral feeds - Chest drain + P/F ration <300 = ARDS
- Taper oxygen
- Shift to ward MANAGEMENT: Advanced
ventilator support

No role of steroids or routine antibiotics

Antibiotics if fever and respiratory distress reoccur or persist beyond 48 hours or if radiological findings worsen
Other supportive care
Counselling for prevention of recurrence

When to refer/ Things to do before referral:

• Complete the emergency management
• Ventilator support not available
• Deterioration of condition with multiple complications

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Management of Acetaminophen (Paracetamol) Poisoning

Single or repeated doses more than 150 mg/kg or 4 grams in adolescent in 24 hours cause severe hepatic necrosis
and sometimes acute tubular necrosis of the kidneys.

Flowchart for management of acetaminophen poisoning

History of ingestion of acetaminophen (especially >150 mg/kg)

Decontamination:
• Gastric lavage (if consumption < 1 hour; longer if it is sustained release tablet
• Activated charcoal via NG tube: 1g/kg

< 4 hours 4- 8 hours > 8 hours

• Observe
• Estimation of drug levels • Estimation of drug levels
• Estimation of drug level at 4
hours
• Start NAC infusion • Start NAC infusion
• Decide on drug levels & risk
factors like malnutrition,
prolonged fasting, liver enzyme
inducing drugs, hepatic injury

Decide to start NAC based on

Once result is available, if Stop NAC, if both level is
levels & high risk factors as per
level is normal, stop NAC normal & LFT is normal
Nomogram

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N- acetylcysteine (NAC) Dose Regimen:

Oral regimen
• Loading dose: 140 mg/kg followed by 70 mg/kg 4 hourly for 17 additional doses (total 1330 mg/kg over 72 hours

IV regimen
• Loading dose: 150 mg/kg over 60 minutes
• Dose 2: 50 mg/kg over 4 hours
• Dose 3: 100 mg/kg over 16 hours

Alternative IV regimen
• Loading dose: 150 mg/kg over 60 minutes followed by 10 mg/kg/h over 24 – 72 hours.

Duration of NAC: Usually oral regimen is for 72 hours and IV for 24 hours.

When to refer /Things to do before referral:

• Complete the emergency management

• Ventilator support if needed and not available
• Deterioration with multiple complication

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Management of OPC Poisoning

Clue to suspect
History of exposure, smell of pesticide
Toxidrome: (clinical Manifestation)
Severe toxicity manifests within 6 hours
Muscarinic effects:*
Nicotinic effects: **
Central nervous system: (Agitation, tremors, altered consciousness, and seizures)

Investigations
Estimation of pseudocholinesterase in the blood and RBC cholinesterase (more specific) for confirmation of the
diagnosis.

Atropine test: if doubt exists, a trial of atropine of 0.01-0.02 mg/kg IV is given. The subsidence of signs or
symptoms of cholinergic effects strongly supports the diagnosis. (Diarrhoea, diaphoresis, urinary frequency,
miosis, bradycardia, bronchorrhoea, bronchospasm, emesis, lacrimation, salivation, seizures)

Supportive laboratory tests: CBC, sugar, electrolytes, RFT, LFT, ECG, amylase

Management
Airway and breathing: Positioning, clearing of secretions and ventilation if needed (may need prolonged
ventilatory support).
Circulation: Judicious fluid, inotropes and vasopressors.
Decontamination:
Gastric lavage
- Activated charcoal: 1 gm/kg within 1 hour of ingestion
Removal of all clothing and wash skin with soap and water
Mild cases:
Decontamination and close monitoring for 48 -72h
Moderate and severe cases:
- Continue support of ABC
- Ventilatory support
- Atropine (maintenance drip is continued for 24-48 hours or longer)
- Pralidoxime (Continue til clinical recovery or 12-24 hours after atropine has been stopped or 7 days have
lapsed)

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Doses
Atropine: 0.05 mg/kg IV every 5 – 20 minutes. It can be doubled if no improvement.
• Continue atropinisation (drying up of secretions and absence of bronchoconstriction) and no tachycardia
and mydriasis.
• Continue infusion at hourly rate of 10-20% of the total atropine dose.

Pralidoxime
• 25-50 mg/kg (maximum dose 2 g) in 100 ml of saline over 30 minutes.
• It may be repeated after 1-2 hours if the muscle weakness is not relieved and then every 10-12 hours if
cholinergic signs reappear.
• A continuous infusion of 10-20 mg/kg/hrs after the initial bolus if improvement seen.

*Muscarinic effects: Diarrhoea, diaphoresis, urinary frequency, miosis, bradycardia, bronchorrhoea, bronchospasm,
emesis, lacrimation, salivation, seizures (DUMBELS), and hypotension and cardiac arrhythmias.

**Nicotinic effects: Mydriasis, muscle cramps, tachycardia, weakness, twitching, fasciculation, fl accid paralysis,
(MTWTF), respiratory failure and hypertension.

When to refer /Things to do before referral:

• Complete the emergency management

• Ventilator support not available
• Deterioration of condition with multiple complications

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Identification and Management of a Child with Acute Onset of Coma

Identification and Management of a Child with an Acute Decreased Conscious level (DeCon)
ABCCCDE Assessment and
Treatment

A Intubate if GCS < 9 or if there is suspected/proven raised

intracranial pressure See 'signs of raised ICP box'
Core Investigations Start
Observations
B High Flow O2 if SpO2 <94%, look for acidotic breathing
glucose (capillary, venous)
blood gas (arterial, venous)

C Urine dipstick Record Hourly:

If circulation compromised and signs of raised ICP or DKA,
Coma is give 10ml/kg isotonic fluid bolus
Electrolytes, renal, LFTs, CBC
Blood Culture
HR, RR, SpO2, BP, Temp,
physical appearance
C *Perfom rapid bedside glusoce
If glucose <54mg/dL/3mmol/L, give 5ml/kg of 10%
Continuous
glucose SpO2, ECG
C If clinical diagnosis of raised ICP before imaging
consider sedation, intubation and ventilation and
normalise CO2
D Look or signs of dehydration
Consider differential
diagnoses
E Rash, odour, injury

DIFFERENTIAL DIAGNOSIS NEUROLOGICAL ASSESSMENT

AVPU SCALE: A = Alert ( GCS15) V = Responds to voice(13)
P = Responds to pain (8) U = Unresponsive (6)
GLASGOW COMA SCALE ((GCS))
Diagnosis
Diagnosis Eyes Motor Voice
Differential 4 Open 6
Obeys
5
Converses
commands

Localises pain Confused

Treatment 3 To Command 5 4
Investigation Flexion Inappropriate
Reassessment 2 To Pain 4 withdrawal 3 words

Abnormal Incomprehensible
1 No response 3 2
PICU flexion
Treatment
Abnormal
b l No response
2 extension 1

Raised ICP
No response No response
1
Prolonged fits/Post convulsive GCS MODIFICATIONS IN < 5 YEARS
• See ‘signs of raised ICP’ box
• Mg2+ and Ca2+ and Na+ Motor Voice
Investigation Diagnosis • Refer to NICE bacterial meningitis and
Discuss treatment if : meningococcal septicaemia guideline Normal spontaneous Alert, babbles, coos, words
• Na<125mmol/L 6 movements 5 or sentences to usual ability
• Ionised Ca2+ < 0.75mmol/L Treatment
• Discuss acute management with local PICU Localises to supraorbital pain Less than usual ability,
PICU • Mg2+ M 0.65 mmol/L • Position head in midline 5 or withdraws from touch 4 irritable cry
And convulsion ongoing despite treatment • 20o head up tilt
• Avoid internal jugular CVCs 4 Withdraws from nailbed pain 3 Cries to pain
PICU
Metabolic •
•
Isotonic fluids (restricted)
Mannitol or hypertonic saline 2 Moans to pain
• Intubate and ventilate to PaCO2 4.5-5
Hypoglycaemia • Hypoglycaemia screen if glucose OBSERVATION NORMAL RANGES
<54mg/dl(3mmol/L)
• 5ml/kg bolus 10% glucose
• Follow with infusion of 10% glucose (aim 4-
Intracranial infection Age Resp Rate Heart Rate Systolic BP
7mmol/L) • Bacterial meningitis Neonate 60 160 70
DKA
Differential • Herpes Simplex Encephalitis (HSE)
• See DKA guidelines • Intracranial abscess <1 year 35-45 110-1160 757
• TB meningitis
Hyperammonaemia • If plasma level >100micromol/L
1-5 years 25-30 95-140 80-90
• Free flowing ammonia sample to lab (will need • LP including CSF HSV PCR
to notify lab and transport on ice) Investigation Only if no contraindications 5-12 years 20-25 80-120 90-110
• SEEK EXPERT METABOLIC ADVICE
• Bacterial : See NICE guidance CG102 >12 years Adult Adult 100-120
Unclear cause Treatment • HSE : Acyclovir (consult local ID)
• TB: See NICE guidance CG117 SIGNS OF RAISED ICP
Investigation Consider additional tests and involvement of
specialists e.g. Neurology / Metabolic team
• CT / MRI BRADYCARDIA HYPERTENSION
or
Alcohol Intoxication
• LP (heart rate < 60) (MAP > 95th centile for age)
• Urine Toxicology Pupils abnormal: dilatation Loss / impairment of reaction to
• Urine organic and plasma aminoacids Investigation • Consider blood alcohol test (unilateral or bilateral) or liight
• Plasma lactate
• EEG • ABCD / APLS Abdnormal breathing pattern or Abnormal posture
• Treat hypoglycaemia and start
maintenance
Hypertensive encephalopathy Treatment • Caution for respiratory failure / aspiration LP warning: Do not attempt an LP if:
/ hypotension
• Look for signs of raised ICP / papiloedema • There are signs of raised ICP (even if GCS 15)
• Other concurrent investigation
Investigation • 4 limb BP
• Avoid emetogenic drugs • GCS < 8 or deteriorating or focal neurological signs
• Urinalysis for blood/protein & U&E
or GCS < 12 after seizure lasting >10 minutes
PICU & • Discuss with hypertensive (BP >95th centile for
Consider • Consider other contributory drugs • CT/MRI suggesting CSF pathway obstruction
Nephrology • Consider contacting local poisons unit
age • Low platelets, abnormal coagulation
• Clinical evidence of shock / meningococcal disease
Reproduced and adapted with permission from RCPCH, UK

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 Nepal Paediatric Society
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Treatment of Prolonged Paediatric Seizures

START THE CLOCK: 0 seconds Don’t Ever Forget Glucose:
ABCCCD : recognise and treat : at all times if blood glucose <3mmol/L /
A: Airway obstruction requiring a jaw thrust, or Airway adjunct? <54mg/dLor cannot measure, treat
B: Respiratory failure? immediately with 5ml/kg 10%
C: Shock? Dextrose
C C: Raised intracranial pressure, trauma, encephalopathy or focal
neurology Give IV calcium if infant <3 months
D: Signs dehydration?
ABC problem YES ABC problem NO ABC problem NO

Treat ABC first and always IV access: YES IV access: NO

keep checking ABC

IV Diazepam 0.2mg/kg OR Rectal Diazepam 0.5mg/kg

5 minutes IV Lorazepam 0.1mg/kg (max 4mg) OR
IV Midazolam 0.2mg/kg

10 minutes IV Diazepam 0.2mg/kg OR

IV Lorazepam 0.1mg/kg (max 4mg) OR Rectal Diazepam 0.5mg/kg
IV Midazolam 0.2mg/kg

15 minutes Seizure uncontrolled or recurrence?

IV/IO Phenytoin 20mg/kg over 30mins

45 minutes Seizure uncontrolled or recurrence?

IV Sodium Valproate 25 mg/kg over 1-5 minutes (dilute 1:1 with NS)
OR IV Phenobarbitone 20mg/kg over 20 minutes

60 minutes
Seizure uncontrolled or recurrence?
Anaesthetise to terminate seizure
Ketamine 2mg/kg & Suxamethonium 1mg/
kg ABC and basic Neuroprotection
Propofol or midazolam boluses /infusion
All patients Indications for CT scan
• Control ABC • ? raised ICP
• Find and treat cause • ? space occupying lesion
Recheck Glucose and treat with 5ml/kg 10% Dex if <54 mg/dL • Refractory seizures
• IO if no IV access • VP shunt in-situ
• Maintain normothermia • Trauma
• Treat infection: IV ceftriaxone 80mg/kg & aciclovir • New focal seizure
• Treat hyponatraemia <125 mmol/L with 3-5 mls/kg of • New neurological deficit
2.7% sodium chloride • New prolonged seizure
• Do not LP • NAI
• Check ammonia • Intracranial infection

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Newborn Resuscitation Algorithm

Antenatal counselling
Team briefing and equipment check

Dry after birth

Delayed cord
clamping (1-3
Breathing OR crying ?
Yes min) and Routine
No Newborn Care

Dry and maintain normal

temperature, position airway, dry
and stimulate, clear secretion if
needed

60 seconds
A Evaluate respiration

Apnoea or Gasping Labored breathing or

grunting
Start B&M ventilation
Rate 40-60 BPM, Give supplemental oxygen,
B SPO2 monitor if available monitor SPO2 if possible

Continue
No
HR<100 bpm B&M V/Post Targeted pre-ductal
Yes resuscitation saturations after birth
care
Check chest movement, (right arm)
ventilation corrective measure 1 min 60-65%
2 min 65-70%
No 3 min 70-75%
HR < 60 bpm
C
4 min 75-80%
Yes
5 min 80-85%
Chest compression coordinated with B&M at
3:1 ratio. Rate of 100-120 BPM (ECG monitor 10 min 85-95%
if available). Reassess ABC every 30 seconds
Ventilation corrective steps
M - mask reposition
HR < 60 bpm R - reposition airway
D
S - suction mouth and nose
IV Adrenaline (1:10,000) 0.1-0.3 ml/kg IV O - open mouth
P - increase pressure
Update parents and debrief team A - alternative airway

46
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NEPAS Standard
Initial Newborn Care and Kangaroo Mother Care
Maya ko Angalo

ADAPTED FROM WHO Kangaroo Mother Care: a practical guide 2003

CARE FOR ALL BABIES

Initial post-delivery care for all babies:

Skin-To-Skin Care
- Recommended for all babies immediately after delivery to ensure warmth.
- It is also a recommended method when transferring sick newborns to a health facility.

Delayed Cord Clamping

- 1 – 2 minutes

Temperature
- Dry baby then skin to skin care with mum
- Hat, warm blankets
- Skin to skin can happen while cord still unclamped

Early Breastfeeding
- Initiate breast feeding within first hour for all well babies
- Feed on demand- at least 8 times in 24 hours

Feed more frequently if:

- Baby has low blood sugar
- Is small for dates
- Is on standard phototherapy
- If mother feels that there is not enough milk - suckling will encourage lactation

A hungry baby (>34 w) will suckle well and stimulate lactation

If baby is more premature:

- Express milk
- Give by cup or naso-gastric tube

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KANGAROO MOTHER CARE

What is KMC

KMC is a method of caring preterm infants by skin-to-skin contact with the mother or Premature: < 37 weeks
family member. LBW 1.5 - 2.5 kg
Recommended routine care for all LBW (<2kg) VLBW 1.0 - 1.5 kg
ELBW <1.0 kg
3 components:
- Early, prolonged, and continuous skin-to-skin contact between the mother (or substitute) and her baby
- Exclusive breastfeeding or feeding with breast milk
- Facilitating early safe discharge home with regular follow up

When to start KMC

Should be initiated in healthcare facilities as soon as the newborns are clinically stable. (i.e. those who can breath air
and have no major health problems)

KMC recommends continuous or as close to continuous skin-to-skin contact as possible.

>1800g + stable Start KMC immediately after birth

1500- 1800g Admit baby to SNCU for first few days due to risk of complications
Start intermittent KMC* in SNCU
Once stable start continuous KMC
<1500g NICU admission for preterm care for days to weeks before starting KMC.

*Intermittent KMC - Few sessions of KMC per day started from SNCU or NICU and duration of each session should
be not less than an hour.

When to discharge home

Once continuous KMC is established, mother-baby dyad can be discharged from hospital once they fulfil discharge
criteria:
- Parents are confident to care the baby at home and ready to bring back the baby for scheduled follow-up
- Baby is feeding well, gaining adequate weight : weight gain of > 15-20gm/kg/day for 3 consecutive days, on
exclusive breast feeding
- Maintaining stable body temperature in KMC position
- All other treatments e.g. phototherapy and antibiotics have been completed
- As a guide, services must plan at least 1 visit for every preterm week

Why do KMC?
Temperature regulation:
Baby stays warmer by keeping the baby skin-to-skin with the mother or a substitute such as the father.

Supports nutrition:
Through continuous skin to skin contact mother can breastfeed her baby frequently and exclusively
Mother makes more milk and has a better chance of breastfeeding
Baby has improved weight gain

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Multiple additional benefits:

- Baby has decreased pain - Baby cries less and has lower stress levels
- Reduces risk of cross infection - Baby has improved sleep
- Baby has improved heart rate and breathing rate - Improves baby and caregiver bonding
- Tactile stimulus reduces apnoea episodes - Baby has better brain growth and development

How to do KMC

For Staff For Parents

• Be aware of plan for KMC • Shower before coming to hospital
• Be available to assist mother/caregiver with positioning, • Ensure no rashes or wounds on chest
ensure monitoring attached if required etc. • Wear loose fitting shirt
• KMC can be done at baby’s cotside in a chair • Do not smoke before doing KMC
• Keep room warm but not too hot • Eat and use toilet before starting KMC
• Position baby upright between breasts, skin to skin • Baby should only be in nappy, no other clothes
• Mother and baby covered with blanket or mother's shirt • Mother/ caregiver should have baby on their bare
• Ensure mother comfortable chest (no bra)
• Advise parents to plan to spend at least 1 hour doing • Blanket/ shirt over both baby and mother/caregiver
KMC at a time • Make yourself comfortable; feet up, rest and enjoy
time with your baby

Starting KMC in your hospital: What to consider

Awareness
Training and information for staff and parents
- KMC should be discussed with mother as soon as preterm baby is born the mother as soon as a preterm baby is
born and offered to her as an alternative to the conventional methods when the baby is ready.
- KMC does not require any more staff than conventional care. Existing staff (doctors and nurses) should have basic
training in breastfeeding and adequate training in all aspects of KMC as described in this Standard.

Practicalities
- Doing bedside KMC even on sickest babies: Keep monitoring on
- Food and water for mothers
- Comfortable bed / chair
- In the room support
- Open clothing for mums and changing place

Privacy
- Privacy with screens
- Enough space around cot for reclining chair
- Reduce noise

Record keeping
- Documenting length and frequency of KMC sessions

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Paediatric Vital Signs

Age Heart Rate Respiratory Rate

25 - 50
Newborn - 3 months 120 - 160
(up to 60 in newborns)

4 months - 11 months 110 - 160 25 - 45

12 - 24 months 100 - 150 20 - 35

2 - 4 years 90 - 140 20 - 30

5 - 11 years 80 - 120 16 - 30

>12 years 60 - 110 12 - 20

Adapted from APLS

Oxygen targets:
• Known Pneumonia or Bronchiolitis: Aim SpO2 >92%
• In all other cases: Aim Sp02 >94%

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 Nepal Paediatric Society
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F-75 Reference Card - Volume of F-75 to give for children of different weights

Volume of F-75 per feed (ml)a

Weight of child Daily total 80% of daily totala
Every 2 hoursb Every 3 hoursc Every 4 hours
(kg) (130 ml/kg) (minimum)
(12 feeds) (8 feeds) (6 feeds)
2.0 20 30 45 260 210
2.2 25 35 50 286 230
2.4 25 40 55 312 250
2.6 30 45 55 338 265
2.8 30 45 60 364 290
3.0 35 50 65 390 310
3.2 35 55 70 416 335
3.4 35 55 75 442 355
3.6 40 60 80 468 375
3.8 40 60 85 494 395
4.0 45 65 90 520 415
4.2 45 70 90 546 435
4.4 50 70 95 572 460
4.6 50 75 100 598 480
4.8 55 80 105 624 500
5.0 55 80 110 650 520
5.2 55 85 115 676 540
5.4 60 90 120 702 560
5.6 60 90 125 728 580
5.8 65 95 130 754 605
6.0 65 100 130 780 625
6.2 70 100 135 806 645
6.4 70 105 140 832 665
6.6 75 110 145 858 685
6.8 75 110 150 884 705
7.0 75 115 155 910 730
7.2 80 120 160 936 750
7.4 80 120 160 962 770
7.6 85 125 165 988 790
7.8 85 130 170 1014 810
8.0 90 130 175 1040 830
8.2 90 135 180 1066 855
8.4 90 140 185 1092 875
8.6 95 140 190 1118 895
8.8 95 145 195 1144 915
9.0 100 145 200 1170 935
9.2 100 150 200 1196 960
9.4 105 155 205 1222 980
9.6 105 155 210 1248 1000
9.8 110 160 215 1274 1020
10.0 110 160 220 1300 1040

a
Volumes in these columns are rounded to the nearest 5ml.
b
Feed 2-hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea <5 watery stools
per day), and finishing most feeds, change to 3-hourly feeds.
c
After a day on 3-hourly feeds: If no vomiting, less diarrhoea, and finishing most feeds, change to 4-hourly feeds.

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Volume of F-75 for Children with severe (+++) Oedema

Weight Volume of F-75 per feed (ml)a
Daily total 80% of daily totala
with +++ oedema Every 2 hoursb Every 3 hoursc Every 4 hours
(100 ml/kg) (minimum)
(kg) (12 feeds) (8 feeds) (6 feeds)
3.0 25 40 50 300 240
3.2 25 40 55 320 255
3.4 30 45 60 340 270
3.6 30 45 60 360 290
3.8 30 50 65 380 305
4.0 35 50 65 400 320
4.2 35 55 70 420 335
4.4 35 55 75 440 350
4.6 40 60 75 460 370
4.8 40 60 80 480 385
5.0 40 65 85 500 400
5.2 45 65 85 520 415
5.4 45 70 90 540 430
5.6 45 70 95 560 450
5.8 50 75 95 580 465
6.0 50 75 100 600 480
6.2 50 80 105 620 495
6.4 55 80 105 640 510
6.6 55 85 110 660 530
6.8 55 85 115 680 545
7.0 60 90 115 700 560
7.2 60 90 120 720 575
7.4 60 95 125 740 590
7.6 65 95 125 760 610
7.8 65 100 130 780 625
8.0 65 100 135 800 640
8.2 70 105 135 820 655
8.4 70 105 140 840 670
8.6 70 110 145 860 690
8.8 75 110 145 880 705
9.0 75 115 150 900 720
9.2 75 115 155 920 735
9.4 80 120 155 940 750
9.6 80 120 160 960 770
9.8 80 125 165 980 785
10.0 85 125 165 1000 800
10.2 85 130 170 1020 815
10.4 85 130 175 1040 830
10.6 90 135 175 1060 850
10.8 90 135 180 1080 865
11.0 90 140 185 1100 880
11.2 95 140 185 1120 895
11.4 95 145 190 1140 910
11.6 95 145 195 1160 930
11.8 100 150 195 1180 945
12.0 100 150 200 1200 960
Volumes in these columns are rounded to the nearest 5ml. Feed 2-hourly for at least the first day. Then, when little
or no vomiting, modest diarrhoea (<5 watery stools per day) and finishing most feeds, change to 3-hourly feeds.
After a day on 3-hourly feeds: if no vomiting, less diarrhoea, and finishing most feeds, change to 4-hourly feeds.

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F-100 Reference Card - Range of Volumes for Free-Feeding with F-100

Range of volumes per 4-hourly feed Range of daily volumes of F-100

Weight of of F-100 (6 feeds daily)
Child (kg) Minimum (ml) Maximum (ml)a Minimum Maximum
(150 ml/kg/day) (220 ml/kg/day)
2.0 50 75 300 440
2.2 55 80 330 484
2.4 60 90 360 528
2.6 65 95 390 572
2.8 70 105 420 616
3.0 75 110 450 660
3.2 80 115 480 704
3.4 85 125 510 748
3.6 90 130 540 792
3.8 95 140 570 836
4.0 100 145 600 880
4.2 105 155 630 924
4.4 110 160 660 968
4.6 115 170 690 1012
4.8 120 175 720 1056
5.0 125 185 750 1100
5.2 130 190 780 1144
5.4 135 200 810 1188
5.6 140 205 840 1232
5.8 145 215 870 1276
6.0 150 220 900 1320
6.2 155 230 930 1364
6.4 160 235 960 1408
6.6 165 240 990 1452
6.8 170 250 1020 1496
7.0 175 255 1050 1540
7.2 180 265 1080 1588
7.4 185 270 1110 1628
7.6 190 280 1140 1672
7.8 195 285 1170 1716
8.0 200 295 1200 1760
8.2 205 300 1230 1804
8.4 210 310 1260 1848
8.6 215 315 1290 1892
8.8 220 325 1320 1936
9.0 225 330 1350 1980
9.2 230 335 1380 2024
9.4 235 345 1410 2068
9.6 240 350 1440 2112
9.8 245 360 1470 2156
10.0 250 365 1500 2200

Volumes per feed are rounded to the nearest 5ml

a

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